nhscfa business plan 2018-19 - nhs counter fraud authority the police and other crime prevention...

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    NHS fraud. Spot it. Report it. Together we stop it.

    Business plan 2018-19 April 2018 Version 1.0

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    Version control

    Version Name Date Comment

    1.0 Richard Hampton 06/04/18 Final version

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    Table of contents

    Executive summary ..................................................................................... 4

    1. About us ................................................................................................ 7

    Our strategic approach .................................................................................................... 8

    Organisational objectives ................................................................................................. 9

    Our values ..................................................................................................................... 10

    2. Context ................................................................................................ 10

    3. Organisational priorities .................................................................... 11

    4. Evaluation ........................................................................................... 13

    Performance measures ................................................................................................. 13

    Review of performance .................................................................................................. 13

    Appendix 1 – Control strategy priority areas ........................................... 15

    Appendix 2 – Core business objectives ................................................... 20

    Appendix 3 – Our structure .................................................................... 24

    Appendix 4 DHSC AFU strategic objectives ........................................... 26

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    Executive summary The NHS Counter Fraud Authority (NHSCFA) is a special health authority with a remit to identify, investigate and prevent fraud within the NHS.

    Established in November 2017, the NHSCFA is independent from other NHS bodies and directly accountable to the Department of Health and Social Care (DHSC).

    The DHSC Anti-Fraud Unit (DHSC AFU), as the NHSCFA’s departmental sponsor, recognises that the assessment of intelligence enables both the identification of key fraud risks and national prioritisation of action to tackle them. The DHSC AFU defines four key areas of work at the root of this intelligence led strategy:

     Inform and Involve – ensuring a high level of counter fraud awareness and identification and ownership of fraud risks across the NHS, the wider Health Group and stakeholders. It is also vital to have wider public engagement and support for this work. The NHSCFA will work to continue to change the culture and perceptions of fraud so it is not tolerated at any level. Working relationships with stakeholders will be strengthened and maintained through active engagement. The NHSCFA will proactively publicise the dangers of fraud and their success in tackling it.

     Prevent and Deter – working collaboratively to develop solutions at the earliest possible stage and undertaking urgent prevention and deterrence interventions when a problem is identified. Preventing and deterring crime across the NHS and the wider Health Group reduces the opportunity for fraud to occur or to re- occur, and will discourage those individuals who may be tempted to commit fraud. Finding a permanent solution to eradicate identified areas of fraud and emerging risks is more effective than detection and punishment. Those individuals who are not deterred should be prevented from committing fraud by robust systems, which will be put in place in line with policy, standards and guidance. The NHSCFA will work with the DHSC AFU who will coordinate the national response to the problem and hold Health Group to account.

     Investigate & sanction - thoroughly investigate allegations of fraud to the highest professional standards and, where appropriate, seek the full range of civil, criminal and disciplinary sanctions. Those who have committed fraud against the health service will be identified, prosecuted where appropriate and redress for losses will be sought. Redress will be pursued by restraining assets and enforcing recovery through the relevant legal channels in partnership with the police and other crime prevention agencies as appropriate.

     Continuously review & hold to account - fraud does not stand still and continuous re-evaluation and improvement is needed. Where this does not take place, or where there is reticence to do so, then organisations must be held to

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    account for their inaction. It is important that progress is evaluated in tackling fraud to ensure that all involved in addressing the risks are ahead of the evolving fraud problem. The nature of fraud, as an often hidden or silent crime, can make this evaluation challenging. It must also be considered that fraud cannot simply be perceived in terms of the financial loss but also in terms of harm to the organisation, its reputation and its patients in ways that cannot be measured in financial terms.

    The NHSCFA will work collaboratively with the DHSC and other key stakeholders to deliver its agreed priorities and meet the organisational objectives as set out in the NHSCFA strategy and three year delivery plan. This business plan sets out how the NHSCFA will meet its organisational objectives. Working to the NHSCFA’s values of Fairness, Expertise, Integrity, Objectivity, Professionalism, and Vision, we will deliver our core business objectives and our specific priorities for 2018-19 which are as follows:  Fraud in relation to NHS Help with Health Costs (patient charge evasion)

    Patients claiming entitlement to NHS funded treatments or services, such as free or discounted prescriptions, dental treatments or optical services, when they are not eligible is a prevalent fraud risk affecting the NHS

     Pharmaceutical contractor fraud; threats associated with the production and supply of bulk blank prescriptions. Pharmaceutical contractor fraud occurs when these contractors claim for remuneration and the reimbursement of fees by the NHS for services that have not been provided.

     Fraud in relation to procurement and commissioning in the NHS; threats associated with post-contract invoice manipulation Procurement and commissioning fraud in relation to post contract invoice manipulation occurs when payments are made by the NHS from fraudulently submitted claims for work either partially or not carried out.

     Driving improvements in standards of counter fraud work in the NHS The NHSCFA aim to lead, guide and influence the improvement of standards in counter fraud work, in line with HM Government Counter Fraud Professional Standards, across the NHS and wider health group, through review, assessment and benchmark reporting of counter fraud provision across the system.

    Specific priorities are identified through a detailed control strategy process that employs the evaluation of intelligence in our annual Strategic Intelligence Assessment (SIA). The SIA utilises the Management of Risk in Law Enforcement environments (MoRiLE) national model to identify key thematic risk areas and capabilities to take direct action.

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    The structured risk modelling methodology and language used in our assessment is consistent with that used by the vast majority of law enforcement agencies and functions in the United Kingdom. The MoRiLe process considers a number of factors in addition to the loss to fraud estimated in the Strategic Intelligence Assessment which include (among others) the impact on the community, public expectation, reputational and political influences and the capacity and capability of the NHSCFA to effect change.

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    1. About us The NHS Counter Fraud Authority (NHSCFA) is a special health authority charged with the identification, investigation and prevention of fraud within the NHS.

    As a special health authority focused entirely on counter fraud work, the NHSCFA is independent from other NHS bodies and is directly accountable to the Department of Health and Social Care (DHSC). The NHSCFA was established on 1 November 2017.

    Our mission is to lead the fight against fraud affecting the NHS and wider health service, and protect vital resources intended for patient care.

    Our vision is for an NHS that can protect its valuable resources from fraud.

    Our purpose is to lead the NHS in protecting its resources by using intelligence to understand the nature of fraud risks, investigate serious and complex fraud, reduce its impact and drive improvements.

    For the purposes of this document, the term ‘fraud’ refers to a range of economic crimes, such as fraud, bribery and corruption or any other illegal acts committed by an individual or group of individuals to obtain a financial or professional gain.

    From data gathered in 2016-17, in 2017-18 we estimated that fraud losses within the NHS exceeded £1.29 billion per annum1. This should be seen in the context of total health spending of over £120.5 billion2.

    All types of financial loss to the public purse reduce the government’s ability to provide public

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